Provider Demographics
NPI:1871811745
Name:BOLT, LISA KAYE (CPTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KAYE
Last Name:BOLT
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KAYE
Other - Last Name:KISER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPTA
Mailing Address - Street 1:1150 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:67661-1743
Mailing Address - Country:US
Mailing Address - Phone:785-554-2809
Mailing Address - Fax:785-543-6302
Practice Address - Street 1:1150 STATE ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:KS
Practice Address - Zip Code:67661-1743
Practice Address - Country:US
Practice Address - Phone:785-554-2809
Practice Address - Fax:785-543-6302
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02072225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant